MCO Member File to HP

MCO Member File to HP

File name must be in the following format:

Daily: KYDMCMEM_<mcoid>_<ccyymmdd>_<hhmmss>.zip

Monthly: KYMMCMEM_<mcoid>_<ccyymmdd>_<hhmmss>.zip

<mcoid> = 9900004316 (Coventry Cares of Kentucky),

9900004317 (Kentucky Spirit Health Plan),

9900004318(Wellcare of Kentucky).

<ccyymmdd> = The date the file was output in CCYYMMDD format.

<hhmmss> = Time the file was output in hours, minutes and seconds.

The daily file will contain only updates that take place in the MCO system.

The monthly file will contain all data that exists in the MCO system.

Example of daily file name format:

KYDMCMEM_9900004316_20120619_172231.zip (Coventry)

KYDMCMEM_9900004317_20120619_170101.zip (KY Spirit)

KYDMCMEM_9900004318_20120619_171112.zip (Wellcare)

Example of monthly file name format:

KYMMCMEM_9900004316_20120630_175101.zip (Coventry)

KYMMCMEM_9900004317_20120630_173105.zip (KY Spirit)

KYMMCMEM_9900004318_20120630_171141.zip (Wellcare)

The daily file will contain only updates that take place in the MCO system.

The monthly file will contain all data that exists in the MCO system.

Each record will have 80 columns in length.

All of the following record types will be included in one daily or monthly file:

01 Base Information:

Field Name / Type / Len / Description
Record Type / Char / 02 / Record type with value “BI”
Medicaid ID / Char / 10 / Medicaid ID of the member.
Date of Birth / Char / 08 / Member’s date of birth in the format CCYYMMDD.
Social Security Number / Char / 09 / Member’s Social Security Number.
Investigation Indicator / Char / 01 / A value of “Y” indicates the member is under investigation.
A value of “N” indicates the member is not under investigation.
MCO Member ID / Char / 15 / MCO Member ID of the member in the MCO system.
Effective Date / Char / 08 / Effective date of the MCO Member ID in the format CCYYMMDD.
A value of Zero or space is considered invalid.
End Date / Char / 08 / End date of the MCO Member ID in the format CCYYMMDD.
A value of “22991231” denotes the segment is open ended.
When this date is 1 day less than Effective Date, then the transaction represents a Delete Action for a previously transmitted Add or Update transaction
A value of Zero or space is considered invalid.
Filler / char / 18 / Blanks
Carriage Return / char / 01

02 Primary Care Physician:

Field Name / Type / Len / Description
Record Type / Char / 02 / Record type with value ‘PC’
Medicaid ID / Char / 10 / Medicaid ID of the member.
Effective Date / Char / 8 / Effective date the member started with PCP in the format CCYYMMDD.
A value of Zero or space is considered invalid.
End Date / Char / 8 / Date the member ended with PCP in the format CCYYMMDD.
A value of “22991231” indicates the segment is open ended.
A value of Zero or space is considered invalid.
When this date is 1 day less than Effective Date, then the transaction represents a Delete Action for a previously transmitted Add or Update transaction.
A value of Zero or space is considered invalid.
Primary Care Physician ID / CHAR / 10 / Medicaid ID of the Primary Care Physician.
Filler / Char / 41 / Blanks
Carriage Return / char / 01

03 Lock In Information.

Field Name / Type / Len / Description
Record Type / Char / 02 / Record type with value “LI”
Medicaid ID / Char / 10 / Medicaid ID of the member.
Effective Date / Char / 08 / Effective date the member was locked into the provider in the format CCYYMMDD.
A value of Zero or space is considered invalid.
End Date / Char / 08 / The last date the member was locked into the provider in the format CCYYMMDD.
A value of “22991231” denotes the segment is open ended.
When this date is 1 day less than Effective Date, then the transaction represents a Delete Action for a previously transmitted Add or Update transaction
A value of Zero or space is considered invalid.
Lock-In Type / Char / 02 / A value of “M’ denotes the Lock in is for Medical.
A value of “P” denotes the Lock-In is for Pharmacy.
A value of “H” denotes the Lock-In is for Hospital.
A value of “C” denotes the Lock-In is for Control Substance.
Note: There can be multiple records with different Lock-In type for the member.
Provider ID / Char / 10 / Medicaid ID of the Provider the member is locked into.
Date Review / Char / 08 / Date the Lock-In will be reviewed next.
Filler / Char / 31 / Blanks
Carriage Return / char / 01

04 Case and Disease Management Information.

Field Name / Type / Len / Description
Record Type / Char / 02 / Record type with value ‘CD’
Medicaid ID / Char / 10 / Medicaid ID of the member.
Effective Date / Char / 08 / Date the Management is effective in the format CCYYMMDD. A value of Zero or space is considered invalid.
End Date / Char / 08 / Date the Management ended in the format CCYYMMDD.
A value of “22991231” denotes the segment is open ended.
A value of Zero or space is considered invalid.
When this date is 1 day less than Effective Date, then the transaction represents a Delete Action for a previously transmitted Add or Update transaction
Management Type / Char / 01 / A value of C denotes it’s a Case Management.
A value of D denotes it’s a Disease Management.
Note: There can be multiple records with different Management types for the member.
Program Level / Char / 03 / See lists below for CM / DM values
Risk Level / Char / 01 / H = High. M = Moderate. L = Low.
Filler / Char / 46 / Blanks
Carriage Return / char / 01
Case Management Programs: / Acronym
Autism / AUT
Behavioral Health / BLH
Cancer (adult and childhood) / CAN
Catastrophic cases / CAT
Complex Case Management / CCM
Clinically Complex / CCX
Cerebral Palsy / CLP
Co-Morbid Condition Management (CMCM) / CMC
Chronic Renal Failure / CRF
Chronic Pain / CRP
CRIBS (allows early identification and intervention for high risk pregnancies) / CRS
Complex Wounds / CXW
Developmental Delays (when necessary) / DDY
Enhanced Case Management (ECM) / ECM
Case Management of Foster Care and Guardianship / FCG
Case management of members with frequent ER utilization / FER
GI disorders / GID
Hospice (when necessary) / HOS
Maternity/High-Risk OB (HROB) / HRO
Specialty Infusion (home) drugs that are authed through the medical side. / INF
Lead Toxicity / LDT
Medicare members with long term needs / MED
Medically Fragile Children / MFC
Case management of members with multiple inpatient admissions / MIA
Neuromuscular disease / NEM
Neonatal Intensive Care Unit (NICU) / NIC
OB / OBS
OB/Substance abuse / OBA
Coming soon – obesity program / OBY
Special Health Care Needs case management / SHC
Social Needs case management / SND
Traumatic Brain Injury (unless waiver) / TBI
Transition of Care (TOC) / TOC
Transplant / TRS
Disease Management Programs / Acronym
HIV/AIDS / AID
Asthma / AST
CAD / CAD
CHF / CHF
Chronic Kidney Disease / CKD
Chronic Low Back Pain / CLB
COPD / CPD
Crohn's Disease / CRN
Diabetes / DIA
Hemophilia / HEM
HIV / HIV
HTN / HTN
Mental Health referred to MHNet / MLH
MS / MSS
Puff Free Pregnancy / PFP
Smoking Cessation / SCS
Sickle Cell / SKC